Haemorrhoids, known in Ayurvedic classics as Arsha, represent one of the most common anorectal disorders encountered in clinical practice. Characterised by swollen vascular cushions in the anal canal, the condition often manifests with symptoms such as bleeding, prolapse, pain, itching, constipation and a persistent sense of discomfort.1-3 Although not life-threatening, haemorrhoids can significantly impair an individual’s quality of life, affecting daily activities, work productivity and psychosocial well-being. The multifactorial nature of the disease—ranging from sedentary lifestyle and dietary habits to chronic constipation and occupational strain—makes its management a continuing challenge for clinicians.3-5 Conventional surgical procedures, despite being widely practiced, frequently raise concerns regarding postoperative pain, hospitalisation, delayed recovery and risk of recurrence. This has encouraged a shift toward treatment options that are less invasive, cost-effective and capable of providing sustained relief without major complications. Ayurveda, with its holistic and patient-centred approach, offers a distinctive solution through Ksharasutra therapy, a para-surgical technique documented since the time of Sushruta.6-8 Ksharasutra is a medicated thread prepared with herbal alkaline substances and bioactive agents that collectively perform controlled chemical cauterisation, debridement and healing. Its mechanism of action enables simultaneous cutting and healing of pathological tissues, minimising bleeding, reducing infection risk and promoting healthy granulation. Unlike conventional procedures, Ksharasutra requires no major anaesthesia, can be performed on an outpatient basis and allows patients to continue routine activities throughout the treatment period. The therapy has been widely recognised for its effectiveness in haemorrhoids as well as other anorectal disorders including fissure, fistula and pilonidal sinus.9-12 Despite its historical roots, the clinical importance of Ksharasutra continues to expand as more practitioners seek dependable and patient-friendly alternatives to surgical interventions. In the context of haemorrhoids—where recurrence and postoperative complications remain a concern—Ksharasutra presents a uniquely promising therapeutic option. The present research explores its role in modern clinical practice, examining outcomes, symptom relief and the broader therapeutic value of this classical Ayurvedic intervention. Aims and Objectives The aim of this study is to evaluate the clinical effectiveness and therapeutic potential of Ksharasutra therapy in the management of haemorrhoids. The objectives include assessing its impact on key symptoms such as bleeding, prolapse, pain and constipation; examining its ability to facilitate controlled tissue excision with minimal complications; and determining its advantages over conventional surgical approaches in terms of safety, recovery, recurrence and overall patient comfort.

Study Design A prospective, clinic-based observational study was conducted to evaluate the therapeutic efficacy and safety of Ksharasutra therapy in the management of haemorrhoids. The study design adhered to accepted clinical research standards for Ayurvedic para-surgical interventions and followed established ethical principles for human subjects research. Study Setting The study was carried out at Jagat Hospital & Kshara Sutra Center, District Una, Himachal Pradesh, a specialised Ayurvedic anorectal care facility equipped for Ksharasutra preparation and ligation procedures. The centre maintains sterile operating conditions, uniform procedural protocols and standardised postoperative care, ensuring methodological consistency throughout the study period. Patient Selection Inclusion Criteria Patients presenting with classical symptoms of haemorrhoids—including bleeding during defecation, prolapse, pain, itching, constipation or perianal discomfort—were eligible. Diagnosis was confirmed through a detailed clinical examination and proctoscopic assessment. Exclusion Criteria Patients with acute anorectal infections, malignancy, inflammatory bowel disease, uncontrolled systemic disorders, pregnancy, or those requiring emergency surgical intervention were excluded. Individuals on anticoagulant therapy or with significant bleeding disorders were also omitted to maintain procedural safety and accuracy. Diagnostic Evaluation Clinical Examination A comprehensive evaluation was conducted, including medical history, bowel habits, dietary patterns, occupational profile and symptom duration. Local examination assessed external findings, tenderness, prolapse and associated anorectal conditions. Proctoscopic Assessment Proctoscopy was performed to determine the site, grade and origin of haemorrhoids, evaluate mucosal status and rule out coexisting anorectal pathology. This ensured uniform case categorisation and precise treatment planning. Intervention: Ksharasutra Therapy Preparation of Ksharasutra The medicated thread was prepared using the classical Ayurvedic method. Apamarga Kshara served as the alkaline component, Snuhi latex acted as the binding agent and Haridra powder provided antiseptic and healing properties. Multiple coatings were applied sequentially to achieve the desired therapeutic potency. Surgical Procedure Under aseptic precautions and without spinal or general anaesthesia, the haemorrhoidal pedicle was identified, and the Ksharasutra was ligated at its base to induce ischemic necrosis. The method allowed controlled chemical cauterisation, gradual tissue cutting and continuous healing, preserving surrounding anal structures. Post-Procedure Care Patients were advised warm sitz baths, fibre-rich diet, adequate hydration and maintenance of local hygiene. They were instructed to avoid straining during defecation. Analgesics and topical agents were provided as required. Follow-up visits were scheduled to monitor tissue separation, wound healing and symptom regression. Outcome Assessment Therapeutic outcomes were evaluated based on: • Reduction or cessation of bleeding • Regression of prolapse • Relief from pain, itching and constipation • Time and pattern of tissue separation • Development of healthy granulation tissue • Postoperative comfort and mobility • Occurrence of complications or recurrence • Overall functional recovery and patient satisfaction These variables enabled a comprehensive assessment of clinical effectiveness. Data Collection and Analysis All clinical findings were recorded using structured data sheets. Symptom progression, healing characteristics and treatment outcomes were analysed descriptively, with particular emphasis on treatment efficiency, patient tolerability and overall safety of the Ksharasutra procedure.

The demographic distribution revealed that the majority of patients were males (83.20%), with females accounting for 16.80% and no cases in children. Age-wise, haemorrhoids were most prevalent in the 31–40 and 41–50 year groups, each comprising 24.8% of the study population, followed by 51–60 years (19.20%) and 61–70 years (12%). Younger age groups contributed relatively fewer cases, with only 1.6% in the 11–20 range and 13.6% in the 21–30 group, while elderly patients aged 71–80 and 81–90 years comprised 2.4% and 1.6% respectively. Marital status analysis revealed that 91.20% were unmarried, whereas 11.20% were married. Dietary patterns showed a predominance of non-vegetarian intake at 59.20%, while 40.80% followed a vegetarian diet. This demographic profile highlights a strong predominance of haemorrhoids among middle-aged, predominantly male individuals with mixed dietary habits. Table 1: Demographic Profile of Patients Parameter Category Frequency (n) Percentage (%) Sex Male 104 83.20 Female 21 16.80 Child 0 0 Age Group (Years) 0–10 0 0 11–20 2 1.6 21–30 7 13.6 31–40 31 24.8 41–50 31 24.8 51–60 24 19.20 61–70 15 12.0 71–80 3 2.4 81–90 2 1.6 Marital Status Married 14 11.20 Unmarried 114 91.20 Diet Vegetarian 51 40.80 Non-vegetarian 74 59.20 Occupational distribution showed that haemorrhoids were most common among business professionals (30.40%) and service employees (20.8%), followed by labourers (14.4%), retired individuals (16.8%), homemakers (11.2%) and students (6.4%). Symptomatically, pain was the predominant complaint, affecting 76.2% of patients, closely followed by bleeding in 73.5% and prolapse in 69.4%. Constipation was present in 66.66%, itching in 57.14%, and burning sensation in 34%. Discharge was the least common symptom, reported by 8% of patients. This table indicates that haemorrhoids are strongly associated with occupations involving prolonged sitting, physical strain or irregular routines, and present with a consistent cluster of classical anorectal symptoms. Analysis of disease origin showed that the majority of cases were mixed internal–external haemorrhoids (66.4%), followed by internal haemorrhoids (27.2%) and external haemorrhoids (6.4%). Chronicity patterns revealed that symptoms were most commonly present for 1–5 years (47.2%), indicating a prolonged disease course before seeking treatment. Cases symptomatic for less than one year accounted for 13.6%, while chronic cases extending 6–10 years comprised 16.8%. Long-standing haemorrhoids were also observed, with 11–15 year duration in 9.6% and more than 15 years in 12.8% of patients. This profile reflects the typical progressive nature of haemorrhoids and highlights delayed treatment-seeking behaviour. Table-2: Disease Characteristics Parameter Category Frequency (n) Percentage (%) Origin of Haemorrhoids Internal 34 27.2 External 8 6.4 Mixed (Internal-External) 83 66.4 Chronicity <1 year 17 13.6 1–5 years 59 47.2 6–10 years 21 16.8 11–15 years 12 9.6 >15 years 16 12.8 Positional assessment demonstrated a classical pattern, with the majority of haemorrhoids occurring at the 3, 7 and 11 o’clock positions, collectively accounting for 84% of cases. Additional involvement included 7 & 11 o’clock in 6.4%, 3 & 11 o’clock in 3.2% and 3 & 7 o’clock in 2.4%. Isolated haemorrhoids at a single position were less frequent, seen at 3 o’clock and 7 o’clock each in 1.6% of cases, and at 11 o’clock in 0.8%. This distribution aligns with the anatomical positioning of primary anal cushions, confirming the typical haemorrhoidal presentation observed in clinical practice. Prakriti analysis revealed that Vata-Pittaja constitution was the most common among patients (56.8%), followed by Vata-Kaphaja (32%) and Pitta-Kaphaja (11.2%). Disease Prakriti evaluation showed a strong predominance of Vata-Pittaja haemorrhoids (80.8%), with Vata-Kaphaja accounting for 13.6%, Pitta-Kaphaja for 4%, and Sannipataja for 1.6%. These findings reflect the classical Ayurvedic understanding that vitiation of Vata, particularly Apana Vata, plays a central role in the development of haemorrhoids, with Pitta contributing inflammatory changes and bleeding tendencies. Table-3: Prakriti Distribution Parameter Category Frequency (n) Percentage (%) Prakriti of Patient Vata-Pittaja 71 56.8 Vata-Kaphaja 40 32.0 Pitta-Kaphaja 14 11.2 Prakriti of Disease Vata-Pittaja 101 80.8 Vata-Kaphaja 17 13.6 Pitta-Kaphaja 5 4.0 Sannipataja 2 1.6 Treatment outcomes demonstrated that Ksharasutra therapy achieved controlled and gradual separation of haemorrhoidal tissue, with 64.8% of cases separating in seven days or more, 23.2% in six days and 12% within five days. Importantly, no major complications or recurrence were observed throughout the treatment period, reflecting the safety and reliability of the procedure. This outcome profile confirms the effectiveness of Ksharasutra therapy in achieving steady tissue excision with excellent healing and without significant postoperative issues. Table-4: Treatment Outcomes of Ksharasutra Therapy Parameter Category Frequency (n) Percentage (%) Cutting Time Up to 5 days 5 12.0 6 days 29 23.2 7 days & above 81 64.8 Complications Major complications 0 0 Recurrence Recurrence observed 0 0

The present study provides a comprehensive clinical evaluation of haemorrhoids and their management through Ksharasutra therapy at a specialised Ayurvedic anorectal centre in District Una, Himachal Pradesh. The demographic pattern clearly indicates a strong predominance of haemorrhoids among males (83.20%), highlighting gender-related variation that has been consistently reported in proctological literature. The highest incidence was observed in the middle-age groups of 31–40 and 41–50 years (each 24.8%), underscoring the influence of occupational pressures, sedentary work habits and irregular dietary practices common in individuals within their most active working years. The dominance of non-vegetarian dietary habits (59.20%) further supports the role of low-fibre diets and erratic eating patterns as major contributors to chronic constipation and anorectal strain. The occupational distribution reinforces this association, with business (30.40%), service (20.8%) and labour professions (14.4%) forming the bulk of cases—groups typically exposed to prolonged sitting, heavy physical exertion or lifestyle imbalance. Symptomatically, the majority of patients presented with classical features of haemorrhoids, including pain (76.2%), bleeding (73.5%) and prolapse (69.4%), alongside high rates of constipation (66.66%) and itching (57.14%). These findings align precisely with the characteristic clinical profile of haemorrhoidal disease, reflecting progressive vascular congestion, mucosal descent and chronic irritation. Disease characteristics demonstrate that mixed internal–external haemorrhoids were the most prevalent type (66.4%), indicating advanced or long-standing pathology. Chronicity data further support this observation, with nearly half of the patients symptomatic for 1–5 years (47.2%) and a sizeable proportion suffering for over a decade. Such delays in seeking specialised care are common in anorectal disorders due to social embarrassment, self-medication and reliance on temporary symptomatic relief. The positional distribution of haemorrhoids showed a classic pattern involving the 3, 7 and 11 o’clock positions in 84% of cases, reflecting the anatomical location of the primary anal cushions. This validates the diagnostic accuracy of the cohort and confirms that the study population represents typical haemorrhoidal presentations rather than atypical or secondary lesions. Prakriti assessment adds an important Ayurvedic dimension to the findings. Vata-Pittaja constitution dominated both patient (56.8%) and disease profiles (80.8%), emphasising the role of Vata vitiation—particularly Apana Vata—in the pathogenesis of haemorrhoids. The presence of Pitta-related symptoms such as burning and bleeding corroborates classical Ayurvedic descriptions. These observations support a personalised interpretation of the condition and the suitability of Ksharasutra within the Ayurvedic framework. The treatment outcomes strongly affirm the clinical effectiveness of Ksharasutra therapy. Most patients experienced tissue separation within seven days or more (64.8%), reflecting the controlled chemical cauterisation mechanism of the medicated thread. Importantly, the procedure was associated with zero major complications and zero recurrence, highlighting its safety and reliability. The absence of spinal anaesthesia, outpatient delivery of care and the ability of patients to maintain routine activities further demonstrate the therapeutic advantages of Ksharasutra over conventional surgical modalities, which often require hospitalization and involve prolonged recovery. Overall, the findings of this study align closely with both classical Ayurvedic principles and contemporary clinical understanding of haemorrhoids. They underscore that Ksharasutra therapy is a minimally invasive, effective and patient-friendly intervention capable of addressing symptomatic relief, structural correction and healing simultaneously.13-15 The results support its continued use in clinical practice and highlight the need for larger comparative studies to further validate its superiority over standard surgical approaches. Strengths and Limitations This study is strengthened by its prospective design, clear diagnostic criteria, and uniform Ksharasutra technique performed at a specialised anorectal centre, ensuring consistency in assessment and intervention. The structured documentation of demographic patterns, clinical symptoms, disease characteristics and Prakriti considerations provides a comprehensive and reliable clinical profile of haemorrhoids. The absence of major complications and recurrence during treatment further supports the safety of the therapy. However, the study’s single-centre setting and observational nature limit the generalisability of the findings. The lack of a comparative control group and absence of long-term follow-up restrict conclusions regarding superiority over other treatments or the durability of outcomes. Despite these limitations, the study offers meaningful clinical evidence supporting Ksharasutra as an effective, minimally invasive option for haemorrhoid management.

Ksharasutra therapy proved to be a safe, effective and minimally invasive modality for the management of haemorrhoids, offering consistent improvement across key symptoms such as bleeding, prolapse, pain, constipation and itching. The majority of patients achieved controlled tissue separation within the expected timeframe, and notably, no major complications or recurrence were observed, underscoring the reliability of the procedure. Its outpatient feasibility, freedom from spinal anaesthesia and preservation of routine activities further highlight its practical advantages over conventional surgical methods. Overall, the findings reaffirm the therapeutic potential of Ksharasutra as a clinically beneficial and patient-friendly option in haemorrhoid care, supporting its continued inclusion in contemporary proctology and warranting further comparative studies to strengthen the evidence base.

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